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awnoles
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What measures are included in assessing Vital Signs?
- Temperature
- Pulse
- Respirations
- Blood Pressure
- Pain
- O2 Saturation
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What is the frequency of monitoring vital signs in the Hospital?
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What is the frequency of monitoring vital signs in the Home Health Setting?
Each Visit
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What is the frequency of monitoring vital signs in the Clinic?
Each Visit
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What is the frequency of monitoring vital signs in the Skilled Nursing Facilities (SNF)?
Weekly to Monthly
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The frequency of monitoring vital signs is determined by what 3 things?
- Physician's Order &/or Nursing Judgement
- Client's Condition
- Facility Standards
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When do you measure Vital Signs?
- On admission to the Hospital
- Before, during and after a surgery or a procedure
- After a medication administration
- When there is a change in a client's condition
- Before, during and after a blood transfusion
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What should you do to be ready to measure Vital Signs? (3 things)
- -Be organized in approach
- -Be aware of needed equipment
- -Know the baseline vital signs for the client and the normal ranges for the population
(The patient needs to be confident in you)
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When should you report Abnormal Vital Signs?
Immediately
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Who should you report Abnormal Vital Signs to?
- The Student to the Instructor
- then to the RN
- then to the Charge RN
- then to the MD
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When should you report Abnormal Vital Signs?
- When Abnormal
- When they Return to Normal or Change
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How should you report Abnormal Vital Signs?
- 1st - Verbally to appropriate person
- 2nd - Document VS in patient's records
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Define Temperature.
The degree of heat maintained by the body
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What is the equation for body temperature?
heat produced - heat loss
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The body's Internal Temp. is known as the ______ Temp.
Core
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What is the Normal Range for the body's Core Temp.?
96.2 - 100.4 F
36.2 - 38 C
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Is the body's Surface Temp. higher or lower than its Core Temp.?
LOWER
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What 2 methods are mainly used to measure the body's Surface Temp.?
Oral & Auxillary (arm pit)
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What 2 methods are mainly used to measure the body's Core Temp.?
Rectal & Tempanic (ear)
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What is the body's Average Surface Temp. Range?
98 - 98.6 F
36.7 - 37 C
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What is the body's thermostat? Its Thermoregulation?
The Hypothalamus
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Does the amount of temperature increase equate to the degree of illness?
No
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What is more important than the increase in temp.?
patterns and continuousness
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Heat Production can be a result of what 5 things?
- Metabolism (BMR - thyroid hormones)
- Skeletal Muscles (break down of fats)
- Nonshivering Thernogenesis (infants)
- Shivering (tells hypothalamus to help)
- Vasoconstriction
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Heat Loss can be a result of what 4 things?
- Radiation (tranfer of heat w/o contact) 50 % of Heat Loss
- Convection
(transfer of heat through air/water)- Conduction
(transfer w/ contact) 15 - 20 % of Heat Loss- Evaporation
(transfer occurs when water is convrted to vapor)
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What type of Heat Loss is perspiration (sweating)?
Evaporation
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What type of Heat Loss occurs when patient lays on a cold x-ray table?
Conduction
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Where is most of the body's heat lost?
on the skin
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What factors affect your body's temperature?
Age, Hormones, Exercise, Circadium Rhythm (sleep cylce), Stress & Emotions, Environment
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Body Temp. is _______ in the morning and _______ in the afternoon
lowest, highest
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Why do infants wear hats?
b/c they lose 30 % of their body's temp. through their head
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Febrile means ______
Elevated temperature
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Afebrile means ______
w/o Elevated temperature
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Pyrexia means _______. It is a response to _______ or _______ or _______.
Fever. Bacterial or Viral infections or Tissue Injury
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What is the body's temp. when it has Pyrexia?
Greater than 100.4 F (38 C)
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What is the body's temp. when it has Hyperpyrexia?
Greater than 105.8 F
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Is a fever always a bad thing? Why/Why Not?
- No - Up to 102.2 F can be beneficial b/c it:
- - enhances immune responce
- - kills/inhibits many microorganisms
- - enhances phagocytosis
- - causes breakdown of lysosomes
- - virally infected cells self destroy
- - releases interferons (protects cells from viruses)
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What cell damage can a high temperature cause in the brain?
- Agitation
- Confusion
- Stupor
- Coma
- Vascular Collapse
- Death
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Heat Exhaustion is:
profuse diaphoresis (sweating) leading to water & electrolyte loss
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Malignant Hyperthermia is a repsonse to _____
Anesthesia
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A Heatsrtoke is:
- A Medical Emergency
- Hot & Dry skin
- no sweating
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What are the levels of Hypothermia?
- Mild = Less than 96.8
- Moderate = 96.7 - 82.4
- Severe = Less then 82.4
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What are the causes of Hypothermia?
- cold weather
- cold water
- lack of shelter/clothing
- surgery (coldness can save cells)
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What tyoe of thermometer would you use on a patient in isolation?
Disposable thermometer
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An Axillary temp. is _____ than an Oral temp.
1 degree cooler
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A Rectal temp. is ______ than an Oral Temp.
1 degree warmer
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What should you do before you administer a rectal thermometer?
- Make sure it is marked RED (Rectal)
- Lube it 1-2"
- **Stop if you feel resistance**
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